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SAN JOAQVIN COLIN'I'Y <br /> ENVIRONMENTAL HEAL:ri Dlil'ARTMi NT <br /> 600 East MAirt Stree.;Stockton,CA 95202-3029 <br /> Telephone.(209)468.3420 Fix:(209)468.3433 We& www.Sj oeyore/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> lYi "� U�j OOU"'j Cj <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE i <br /> Z 5'7� d dl Ja[. '�..,TUvt_u Q_,c L v 3 S l' `-t (� <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING AIDDROSS APPLICANT PHONE#WITH AREA CODE I <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR fCC�# <br /> Closure Installation tERG, Retrofit L/ �(ems j <br /> ACTIVE FACILITY <br /> 2002 FYO03 2004 2006 2066 2007 <br /> $500 FEE INCLUDES FACILITY FEE» 1 TANK(2002-2007) <br /> S550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008 A New $ <br /> Installs as of V1107) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=8161 TANK <br /> + e $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=524,001 FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place <br /> TANK 10#(a): CLOSURE FEE x$2941 TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$2941 FACILITY <br /> i <br /> INSTALLATION PLAN CHECK <br /> Plan Check ana Construction Ins ecllons) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$7541 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK 1D#Is): <br /> TANK RETROFIT REPAIR FEE =$2941 FACILITY use forrnonitorin equipment,s Is buckets,tank sumps,M16F <br /> PIPING REPAIR FEE _$2941 FACILITY use for okuno,under-dispenser containment,act. r <br /> I <br /> MISCELLANEOUS <br /> $ j <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE S 99/HOUR <br /> — $ i <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 981 HOUR <br /> SAMPLING INSPECTION FEE C S 98/14OUR <br /> ALL FEES ARE 19ASED ON TIjq$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br /> OFFICE USE ONLY I <br /> i <br /> SERVICE REOUESYS I FACILITY 10 1 AMOUNT RECEIVED CHECK ri RECEIVED BY DATE REGEIVED) <br /> SR <br /> EH 29 Oat(REVISED oamot) <br /> 90/00 39Vd A90-10NXNa1 EPSTS9E60Z SP:TT ' B00Z/61/90 <br />